The Clinical Neuropsychiatry of Multiple Sclerosis

Multiple sclerosis is the most common neurological disorder of young and middle-aged adults. Dr. Feinstein has done an excellent job in reviewing and clearly presenting the diverse and plentiful literature on the behavioral disorders associated with multiple sclerosis. His review of the literature is critical and insightful, and if this were all, The Clinical Neuropsychiatry of Multiple Sclerosis would be a useful resource for clinicians. He has done much more, however: he has used the behavioral disorders of multiple sclerosis as a springboard for some very interesting discussions of subcortical dementia, the uses of imaging, and neuropsychological tests.

The book has 10 chapters: “Multiple Sclerosis: Diagnosis and Definitions,” “Multiple Sclerosis and Depression,” “Multiple Sclerosis and Bipolar Affective Disorder,” “Multiple Sclerosis and Pathological Laughing and Crying,” “Multiple Sclerosis and Psychosis,” “Cognitive Impairment in Multiple Sclerosis,” “The Natural History of Cognitive Change in Multiple Sclerosis,” “Detection, Management, and Significance of Cognitive Impairment in Multiple Sclerosis,” “Neuroimaging Correlates of Cognitive Dysfunction,” and “Multiple Sclerosis: A Subcortical White Matter Dementia?” There is a very useful summary at the end of each chapter.

The psychopathology associated with multiple sclerosis is considerable: the lifetime incidence of affective disorder is 50% among patients with multiple sclerosis, which means it probably is the highest incidence of affective disorder observed in any neurological disorder, and the rate of suicide among such patients is very high. It is of interest that patients who later develop multiple sclerosis are not at greater risk of affective disorder before they develop the illness. Treatments of the behavior disorders associated with multiple sclerosis are thoroughly discussed, and these treatments are noted to be as effective as they are with psychiatric patients who do not have multiple sclerosis. The author cites a clinical study noting a 20% risk of multiple sclerosis relapse in patients treated with ECT, a finding that, if replicated, has significant theoretical and practical implications.

Because multiple sclerosis has always been considered a disorder of the central nervous system white matter, sparing the gray matter, cognitive dysfunction was believed to be rare in multiple sclerosis. However, the data do not support this. Over 40% of the patients with multiple sclerosis have cognitive impairment. The cognitive symptoms are not the classical symptoms of dementia but are primarily manifested in decreases in attention, speed of information processing, memory, and executive functions. Although there is often a decrement in IQ, it relates more to the performance portion of the WAIS and often improves with remission of the multiple sclerosis. Dr. Feinstein notes, quite justifiably, that the commonly used Mini-Mental State is very poor in picking up the cognitive impairments manifested by multiple sclerosis patients. He goes on to discuss the utility of other neuropsychological tests. There is also a very useful review of other conditions where subcortical dementia has been observed, such as Huntington’s disease, HIV infection, and Binswanger’s disease. Comparing the findings in these conditions with those in multiple sclerosis, Dr. Feinstein he builds a good case for the concept of subcortical dementia.

This is a useful, well-written book that would be of interest to anyone concerned about cognitive dysfunction and the utility of neurological illnesses in illuminating the relationships between brain and behavior.